Gingival Augmentation Research Articles

THE USE OF PLATELET-RICH FIBRIN COMBINED WITH FREE GINGIVAL GRAFT IN THE MANAGEMENT OF INSUFFICIENT ATTACHED GINGIVA AT TEETH WITH GINGIVAL RECESSION

Aim: This study was carried to evaluate the effect of the placement of PRF membrane beneath the free gingival graft in gingival augmentation surgeries regarding the changes by time in graft horizontal dimension, vertical dimension and total surface area.Subjects and Methods: Sixteen patients were selected. All the patients showed gingival recession with insufficient attached gingiva. The gingival augmentation surgery was decided to be performed as a primary surgery to increase the attached gingiva with no attempt to cover the recession during this study. Group 1 (test group) included eight patients where the gingival augmentation was performed using a free gingival graft in combination with a platelet rich fibrin membrane placed beneath the graft at the recipient site. Group 2 (control group) included eight patients where the gingival augmentation was performed using a free gingival graft only. The graft vertical dimension (GVD) and the graft horizontal dimension (GHD) were measured using William’s graduated periodontal probe. Plaque index, gingival bleeding index and probing depth were used to monitor the oral hygiene status and gingival health condition throughout the study. All the measures were obtained at 2 occasions; the day of the surgery and 1.5 months after the surgery.Results: Regarding the changes in GVD, a statistically significant greater mean and median percent decrease was noted in group 2 after 1.5 month. The same was obtained with the changes in GHD and graft surface area.Conclusion: Using platelet-rich fibrin beneath free gingival graft in gingival augmentation surgery resulted in successful increase in the attached gingiva with less dimensional changes by time in the transplanted free gingival graft compared to using free gingival graft alone.

A detailed description and 16-year validation of a new suturing method for stabilizing connective tissue grafts at recipient sites for root coverage and gingival augmentation

Which are the different ways of stabilizing connective tissue grafts (CTGs) for root coverage and gingival augmentation by means of placement of sutures? There are various defined and undefined ways of stabilizing CTGs depending on experience and personal preferences. Most of the techniques profess use of absorbable sutures in separate interrupted fashion (sutures at the corners of the graft wherever possible). This paper describes a new suturing method, "the lingually-tied horizontal mattress contouring suture," for stabilization of CTGs with or without epithelialized collar at the recipient site, for use with papilla retention and sparing techniques to treat marginal tissue recessions. The suturing technique is described in detail. It can be indicated for good number of root coverage cases, with additional objectives of gingival augmentation, specifically developed for papilla sparing and papillary buccal de-epithelialization recipient site preparations. Over a period of last 16 years this suturing technique showed promising results in terms of graft stabilization and survival. The main advantage of this technique lies in the use of cost-effective nonabsorbable sutures that usually retain some amount of tension on the soft tissues longer. The primary objective of the suturing technique, per se, is to stabilize the CTG firmly along the contours of the root surface and to expedite a very close adaptation to the interdental soft tissues as well. The secondary objective of the article or publication is to disseminate the knowledge acquired through long periods of performance and observation for the benefit of the periodontal community as whole. Further validation is advocated.

Soft tissue substitutes to increase gingival thickness: Histologic and volumetric analyses in dogs.

To evaluate the histologic and volumetric changes of gingival tissues following grafting with collagen-based matrices at labial aspect of teeth in canines. Gingival augmentation was performed in the mandibular incisor area using two types of xenogeneic cross-linked collagen matrices (CCMs), bovine CCM for BCCM group and porcine CCM for PCCM group, whereas the contralateral sides remained untreated (B-control group and P-control group). Descriptive histology, histometric and volumetric analyses were performed after 12weeks. For statistical comparison between each test group and respective control group, paired t test was used for histometric analysis, and repeated-measured analysis of variance was used for volumetric analysis (p<0.05). An increased number of rete pegs and an enhanced formation of new blood vessels were observed at both grafted sites compared to the corresponding control sites. There was statistically significant gain of horizontal thickness only in BCCM group (1.36±0.27mm vs. 1.26±0.34mm; p<0.05) compared to the B-control groups. BCCM was effective for gingival augmentation in terms of horizontal thickness at the labial aspect of teeth at 12weeks post-surgery.

Ryzyko powikłań miejsca dawczego na podniebieniu w zależności od długości i grubości przeszczepu dziąsłowego

Autogenous gingival grafts are considered the gold standard procedure with proven clinical success when it comes to gingival augmentation. Different graft harvesting procedures have been described in the literature. Understanding which factors might affect the level of discomfort (morbidity) that patients are likely to experience and oral health-related quality of life outcomes in general seems to be crucial. An evaluation of patients' morbidity depending on the free gingival graft (FGG) dimension. Sixty patients were divided into 3 groups depending on the length of their graft (group L1: ≤10 mm, group L2: 10-20 mm, group L3: ≥20 mm) and into 2 groups depending on the thickness of the graft (group T1: ≤2 mm, group T2: >2 mm). Discomfort at the donor site was evaluated 1 week postoperatively, using a visual analog scale (VAS). With the length of the FGG, the mean VAS scores for pain, bleeding, eating and speaking disorders, stress and interference with social life increased. Analgesic consumption increased with the length of the graft. The thicker the grafts, the less discomfort and pain, and more problems with speaking, stress, daily and work routines occurred; however, without statistical significance. No differences were demonstrated in the post-operative patients' morbidity between the examined groups; however, pain gradually increased with the FGG length and width.

The efficacy of ozone therapy on free gingival graft augmentation around dental implants

The efficacy of ozone therapy on free gingival graft augmentation around dental implants

The use of paquette blade handle in harvesting free gingival graft from the palate – a report of three cases with its method of use, advantages and disadvantages.

Free gingival grafting is a well-known periodontal plastic surgical procedure used for gingival augmentation, for root coverage procedures and in some cases of pre-prosthetic ridge augmentation. Several instruments have been used to harvest the graft from hard palate, ranging from scalpel to mucotome, each of which has its own advantages and disadvantages. One such instrument is Paquette blade handle, which incorporates a regular razor blade for graft harvesting. This article intends to describe in detail the handling of this instrument, its usefulness as well as limitations, as explained in the following three cases.

Free gingival graft: An effective technique to create healthy keratinised gingiva

The high labial frenal attachment in mandibular anterior segment is most commonly associated with inadequate width of attached gingiva. Insufficient attached gingiva contributed to the difficulty in oral hygiene maintenance and ultimately poor gingival health. Frenectomy, vestibular extension and gingival augmentation procedures either alone or in combination are often required to maintain adequate health of the gingiva.

Ultrasound assessment of soft tissue augmentation around implants in the aesthetic zone using a connective tissue graft and xenogeneic collagen matrix – 1-year randomised follow-up

PurposeA comparative, ultrasound evaluation of the thickness of keratinized mucosa (TKT) around implants one year after gingival augmentation (GA) by means of a connective tissue graft (CTG) and the xenogeneic collagen matrix (CMX). Materials and methodsA total of 75 bone level tapered implants (Conelog® Camlog) were inserted in 57 patients in the aesthetic area of both jaws. The patients were divided into 3 groups: control group I- without GA; group II- GA 3 months before implantation, and group III- GA 3 months after implantation. Groups II and III were divided into two subgroups depends on type of material used for GA: (a) CMX (Mucograft®, Geistlich Pharma AG) and (b) CTG. The patients underwent a clinical and ultrasound examination before, then after 3 and 12 months following GA respectively to evaluate TKT at two points using ultrasound equipment (Pirop®, Echoson). Point 1 was considered to be in the middle of the line connecting the cemento-enamel junction (CEJ) to the adjacent teeth, and point 2 on the mucogingival junction (MGJ). ResultsThree months after GA, the highest increase in gingival thickness was noted in group IIIb (point 1 – 0.95mm, 2 – 1.01mm). However, 12 months after GA the highest gingival thickness was observed in group IIb (point 1 – 1.76mm, 2 – 1.36m) and next IIIb (point 1 – 1.52mm, 2 – 1.15mm). ConclusionsBoth CTG and Geistlich Mucograft® increased TKT, but higher values were noted using CTG augmentation before implantation. An ultrasonic device can be used as a non-invasive, reliable, and reproducible method for evaluating TKT.

Effect of laser photobiomodulation on wound healing and postoperative pain following free gingival graft: A split-mouth triple-blind randomized controlled clinical trial

Background and AimFree gingival graft (FGG) is one of the most predictable techniques for gingival augmentation. However, patient's discomfort and pain during healing period are significant concerns. The aim of this study was to assess if laser photobiomodulation (PBM) was effective in terms of enhancing wound healing and reducing postoperative pain. Methods and MaterialsTwelve patients participated in this split-mouth randomized controlled clinical trial. Each patient had a 30-day interval between the two procedures. In the test group, donor and recipient sites received diode laser (660nm, 200mW, continuous mode, time of irradiation:32s, energy density: 4J/cm2, spot size:0.5cm) immediately after FGG surgery, and 1,2,4 and 7days later. The control side received the same sequence of irradiation with the laser-off. Complete wound epithelialization of donor site and clinical wound healing and visual analogue scale (VAS) pain score of donor and recipient sites were evaluated after surgery. ResultsAt 14 and 21days after surgery, the number of donor sites with complete epithelialization was greater in laser group compared to the placebo. After 21days, all donor sites in the test group were epithelialized completely, while at the same time, only eight donor sites in the control group showed complete epithelialization (P value=0.05). In terms of clinical healing of the recipient and donor sites, the test and control groups did not show any significant difference during the 45-day period, except at days 1 (for recipient site) and 14 (for donor site), when the test group showed better results (P values: 0.01 and 0.03, respectively). The VAS pain score did not show statistically significant difference between two groups during the study period, except for the first 3h after procedure when laser group showed greater VAS pain score (P values<0.05). ConclusionPBM following FGG procedure with the parameters used in this study could accelerate the rate of epithelialization at the donor site. However, it did not reduce postoperative pain.

Clinical evaluation of the effects of free gingival and extracellular matrix grafts to increase the width of the keratinized tissue around dental implants

Inadequate keratinized mucosa around dental implants can lead to more plaque accumulation, tissue inflammation, marginal recession and attachment loss. We evaluated the effects of free gingival and extracellular matrix membrane grafts performed to increase the insufficient width of keratinized tissue around dental implants in the posterior mandible. A 47-year-old female patient presented with discomfort due to swelling of the lower right second premolar area. Due to severe destruction of alveolar bone, the tooth was extracted. After 3 months, a guided bone regeneration (GBR) procedure was performed and then a dental implant was placed 6 months later. During the second-stage implant surgery, free gingival grafting was performed to increase the width of the keratinized tissue. After 12 months, a clinical evaluation was performed. A 64-year-old female patient had a missing tooth area of bilateral lower molar region with narrow zone of keratinized gingiva and horizontal alveolar bone loss. Simultaneous implant placement and GBR were performed. Five months after the first-stage implant surgery, a gingival augmentation procedure was performed with an extracellular matrix membrane graft to improve the width of the keratinized tissue in the second-stage implant surgery. After 12 months, a clinical evaluation was performed. In these two clinical cases, 12 months of follow-up, revealed that the increased width of the keratinized tissue and the deepened oral vestibule was well maintained. A patient showed a good oral hygiene status. In conclusion, increased width of keratinized tissue around dental implants could improve oral hygiene and could have positive effects on the long-term stability and survival rate of dental implants. When planning a keratinized tissue augmentation procedure, clinicians should consider patient-reported outcomes.

CO2 Laser-Mediated Apically Positioned Flap in Areas Lacking Keratinized Gingiva.

Autogenous gingival grafts are considered the "gold standard" for gingival augmentation, however they require a second surgical site for graft harvesting. Apically positioned flaps (APFs) represent an alternative method in soft tissue augmentation procedures. Limited information is available relative to the effectiveness of laser-mediated APF in augmenting keratinized gingiva (KG). The aim of this paper is to evaluate soft tissues changes following APF using CO2 laser in mandibular incisors with minimal KG and high labial frenum attachment. A total of 20 patients with minimal amount of KG (< 2 mm) on the labial aspect of one mandibular incisor and high buccal frenum insertion were selected for treatment. Only 19 completed the last follow-up visit. An APF consisting of a single superficial horizontal incision just coronal to the mucogingival junction using CO2 laser, elevation of a split-thickness flap, and suturing of the flap to the periosteum in an apical position was performed. The apico-coronal height of KG was measured at baseline, and at 3, 6 and 12 months postoperatively. Uneventful healing was observed in all patients and an increase in KG of 2-3 mm was obtained. Most patients rated the procedure and the postoperative course as non painful. CO2 laser-assisted APF procedure is a minimally invasive treatment modality associated with reduced risk of bleeding and predictable increase in the height of KG.

Immediate Implant Placement with Simultaneous Regenerative Procedure in Fresh Extraction Socket

ABSTRACT Aim The aim of this case report was to reconstruct the alveolar buccal bone plate lost in consequence of a root fracture in the maxillary central incisor area after immediate implant placement (IIP). A 48-year-old patient was referred to our office with the chief complaint of spontaneous bleeding in his left central incisor. After careful examination, the following comprehensive treatment approach was carried out: (1) Atraumatic tooth extraction, (2) IIP, (3) provisional prosthesis installation, (4) alveolar buccal bone plate reconstruction with autologous bone collected from the maxillary tuberosity, (5) gingival augmentation procedure with connective tissue graft removed from the palate, and finally (6) adjustment of the provisional restoration. After 1-year postoperative, an adequate esthetic outcome was achieved with lower cost, reduced morbidity to the patient, and lower treatment time. This approach was able to improve gingival architecture and bone volume with adequate thickness and width, enhancing patient esthetics and satisfaction. In conclusion, when proper diagnosis, precise surgical techniques, and appropriate multidisciplinary approach are employed, IIP followed by immediate dentoalveolar restoration might be considered a safe procedure to restore the peri-implant bone and gingival recession favoring the achievement of appropriate esthetic outcomes. Clinical significance The treatment planning employed was able to improve gingival architecture and bone volume with sufficient width and thickness enhancing patient esthetics and satisfaction in one single-stage procedure. How to cite this article de Molon RS, de Avila ED, Barros- Filho LAB, Cirelli JA, Borelli-Barros LA. Immediate Implant Placement with Simultaneous Regenerative Procedure in Fresh Extraction Socket. World J Dent 2017;8(3):231-238.

Periodontal Conditions of Sites Treated With Gingival Augmentation Surgery Compared With Untreated Contralateral Homologous Sites: An 18- to 35-Year Long-Term Study.

The aim of this split-mouth study is to compare long-term (18 to 35 years) periodontal conditions of sites treated with gingival augmentation procedures (GAPs) and untreated homologous contralateral sites. Forty-seven patients with 64 sites (test group), with lack of attached gingiva associated with recessions, were treated with marginal or submarginal free gingival grafts. Sixty-four contralateral homologous sites (control group), with or without gingival recession (GR) and with attached gingiva, were left untreated. Patients were recalled every 4 to 6 months during follow-up period. GR depth, keratinized tissue (KT) width, and probing depth were measured at baseline (T0), 1 year after surgery (T1), during follow-up (10 to 27 years, T2), and at the end of the follow-up period (18 to 35 years, T3). Multilevel and regression analyses were conducted. At the end of T3, 83% of the 64 treated sites showed recession reduction (RecRed), whereas 48% of the 64 untreated sites experienced increase in recession. Treated sites ended with gingival margin (GM) 1.7 mm (P = 0.01) more coronal and KT 3.3 mm (P <0.001) wider than untreated sites. In grafted sites, KT at T3 remained stable compared with T1 value (4.1 mm, P <0.001). Sites treated with GAPs resulted in coronal displacement of GM with RecRed up to complete root coverage, whereas contralateral untreated sites showed a tendency to increase in existing recession or develop new recession during the 18- to 35-year follow-up.

Clinical study of the effect of free gingival graft and apically repositioned flap surgery on peri-implant keratinized gingival augmentation

Objective: To compare and analyze the clinical outcomes of apically repositioned flap surgery and free gingival graft on keratinized gingival augmentation. Methods: Totally 30 partially edentulous patients treated with submerged implant surgery in mandibular molar area were recruited and divided into three groups: group 1(mean age: 41 years) and group 2 (mean age: 25 years) received free gingival graft 1 month after submerged implant surgery and second stage implant surgery3 months after submerged implant surgery; group 3(mean age: 44 years) received apically repositioned flap and second stage implant surgery 3 months after submerged implant surgery. The widths of keratinized gingiva were measured respectively at the time before the apically repositioned flap surgery/free gingival graft and 1 month, 6 months after the surgery. The thickness of keratinized gingiva was measured during the operation. Results: The widths of peri-implant keratinized gingiva of group 1 and group 2 were (3.1±1.2) mm and (3.5±1.0) mm 1 month after the free gingival graft surgery, (3.0±1.3) mm and (3.5±1.0) mm 6 months after the free gingival graft surgery, respectively. The widths of peri-implant keratinized gingiva in group 1 and group 2 demonstrated no statistically significant differences(P>0.05). The widths of peri-implant keratinized gingiva of group 3 was (2.6±0.5) mm 1 month after the apically repositioned flap surgery, (1.9±0.3) mm 6 months after the apically repositioned flap surgery, respectively. The widths of peri-implant keratinized gingiva(1 month and 6 months after the apically repositioned flap surgery) in group 3 showed statistically significant differences when compared with group 1 and group 2(P=0.008, P=0.000). Conclusions: The implant area treated with free gingival graft or apically repositioned flap exhibited increased width of the keratinized gingiva. The implants treated with free gingival graft exhibited more increased width of the keratinized gingiva compared with those treated with apically repositioned flap. Age showed little impact on keratinized gingival augmentation.

Long-Term Outcomes of Untreated Buccal Gingival Recessions: A Systematic Review and Meta-Analysis.

This review aims to: 1) assess the long-term outcomes of untreated buccal gingival recession (GR) defects and the associated reported esthetic and functional alterations; and 2) evaluate which factors influence the progression/worsening of dental and periodontal tissue conditions of untreated GR defects. Interventional and observational studies with duration of ≥24 months reporting outcomes from adult patients with localized or multiple GR defects not treated by root coverage or gingival augmentation procedures were considered eligible for inclusion. MEDLINE and EMBASE databases were searched for articles published through July 2015. Random-effects meta-analyses were performed comparing baseline versus most recent follow-up outcomes (i.e., number of patients with ≥1 GR and number of sites with GR). Of 378 potentially eligible articles, eight (reporting six studies) met inclusion criteria. Of 1,647 GR defects with baseline and follow-up information, 78.1% experienced GR depth increase during the follow-up period, whereas the remaining experienced decrease or no change. Moreover, there was a 79.3% increase in the number of GR defects among the patients followed (i.e., new GR defects). Pooled estimates (data from four studies) showed significantly increased odds of recession development long term, regarding either number of patients (odds ratio 2.43; P = 0.03) or number of sites with GR (odds ratio 2.16; P = 0.0005). Untreated recession defects in individuals with good oral hygiene have a high probability of progressing during long-term follow-up.

Effects of Ozone Therapy on the Early Healing Period of Deepithelialized Gingival Grafts: A Randomized Placebo-Controlled Clinical Trial.

This study evaluates the effects of ozone therapy (OT) on the early healing period of deepithelialized gingival grafts (DGG) placed for non-root coverage gingival augmentation by laser Doppler flowmetry (LDF). Thirty-three patients were assigned to study groups: 1) test: DGG + OT; or 2) control group: DGG alone. Thirty patients completed the study. Ozone was applied on DGGs placed in the recipient bed and donor site immediately after surgery and at days 1 and 3 post-surgery. Blood perfusion in the recipient site was measured by LDF on the day of surgery and at 1, 2, 3, 6, 8, 10, and 13 days after surgery. Quality of life (assessed by the Oral Health Impact Profile-14) and pain at donor/recipient sites (assessed by visual analog scale) were also investigated. Increase in blood perfusion units in the test group was significantly higher than control group at 1, 2, 3, 6, and 8 days post-surgery (P <0.001). Significant differences occurred between test and control groups in terms of visual analog scale values during the first week post-surgery for both donor and recipient sites (P <0.05). The ozone-treated group showed significantly higher quality of life than control group on postoperative day 6 (P = 0.002). OT enhanced blood perfusion units in the first postoperative week. This outcome is also consistent with improvement in wound healing, accompanied by an increase in quality of life and decrease in postoperative pain in the test group.

A novel single-step surgical technique for vestibular deepening using laser in conjunction with periodontal flap surgery

Moderate-to-severe chronic periodontitis results in clinical loss of attachment, reduced width of attached gingiva (AG), periodontal pockets beyond mucogingival junction (MGJ), gingival recession, loss of alveolar bone, and decreased vestibular depth (VD). The encroachment of frenal and muscle attachments on marginal gingiva increases the rate of progression of periodontal pockets, prevents healing, and causes their recurrence after therapy. Loss of VD and AG associated with continuous progression of pocket formation and bone loss requires two-stage surgical procedures. In this article, one-stage surgical procedure is being described for the first time, to treat the periodontal pockets extending beyond the MGJ by periodontal flap surgery along with vestibular deepening with diode laser to increase the AG. One-step surgical technique is illustrated whereby pocket therapy with reconstruction of lost periodontal tissues can be done along with gingival augmentation by vestibular deepening.

Coverage Root after Removing Peripheral Ossifying Fibroma: 5-Year Follow-Up Case Report.

When lesions in soft tissue reach the gingival margin, they can produce aesthetic defects during its permanence and after its removal. Periodontal plastic surgery allows the correction of the gingival contour using different techniques. This paper is a case report of a peripheral ossifying fibroma removal in the interproximal area of teeth 21 and 22 in addition to root coverage of the affected area through two surgical phases: keratinized gingival tissue augmentation surgery with free gingival graft concurrent with removal of the lesion and, in a second stage, root coverage by performing coronally advanced flap technique with a follow-up of five years. The initial results achieved, which were root coverage of 100% after 6 months, promoted an adequate gingival contour and prevented the development of a mucogingival defect or a root exposure with its functional and aesthetic consequences. After five years, the results showed long term success of the techniques, where the margin remained stable with complete root coverage and tissues were stable and harmonic in color.

Therapeutic Outcomes for Gingival Recession Defects in the Esthetic Zone: A Systematic Review

Background: The aim of this paper is to review the major quantitative and qualitative therapeutic outcomes for gingival recession defects in the esthetic zone. Methods: PubMed and MEDLINE were searched for entries up to April, 2012. For the assessment of quantitative parameters, criteria for considering studies for this assessment was based on the most current systemic review by Chambrone published in April, 2012. For the assessment of qualitative parameters, only studies that evaluated the soft tissue esthetic outcome of recession areas treated with root coverage procedures were included. Findings: Quantitative measurements of root coverage, such as percentage of root coverage and the percentage of gingival augmentation, provide objective assessment and the advantage of reliability. However, parameters that account for the global esthetic evaluation are not evaluated by the quantitative measurements. On the other hand, qualitative evaluation, such as scarring, texture, volume, color, gingival contour, and the location of mucogingival junction, is subjective and per se imperfect. It is limited to esthetic appearance and cannot replace the clinical quantitative assessment. More explicit criteria are required to improve the reliability of scales for esthetic assessment. Conclusions: The final esthetic goal of a root coverage procedure should include the achievement of complete root coverage and the complete soft tissue integration.

REDUCTION OF MOBILITY OF PERIODONTALY AFFECTED TEETH AFTER GINGIVAL AUGMENTATION WITH AN AUTOGENOUS GINGIVAL GRAFT (Case Report).

INTRODUCTION: The most severe complication of advanced periodontal lesions is the loss of teeth due to terminal attachment loss and high grade mobility. The goals of the treatment are the improving the plaque control stabilizing of the mobile teeth and arresting of the progression of gingival recession achieving gingival augmentation with adequate vestibulum depth. The autogenous graft is considered to be the most efficient approach where a significant increase of the attached gingiva is needed. OBJECTIVE: This presentation demonstrates the capacity of the autogenous gingival graft approach to reduce the high grade tooth mobility and to augment keratinized gingiva. METHODS: V.T. (46) with moderate generalized periodontitis. The examination reveals thin periodontal biotype, Class IV recessions on 31,41 with III grade mobility and terminal attachment loss, narrow vestibulum and lack of attached gingiva. An autogenous graft technique was selected to achieve simultaneous gingival augmentation and correction of vestibulum depth. RESULTS: A significant and stable increase of the attached gingiva is observed which led to better access for oral hygiene thus creating better conditions for successful long-term outcome. The root coverage was more that 40% and the tooth mobility was decreased to grade I. CONCLUSION: In the limitations of the presented case the free autogenous graft technique seems an appropriate approach in cases with deep Class IV recessions and high grade toot mobility in mandibular frontal area creating proper conditions for effective oral hygiene and decreasing tooth mobility by creating a sufficient amount of attached gingiva needed for the long term maintenance.